CurrentFlorida BluePolicy N/A

Provider-Administered Specialty Drugs (medical benefit list)

List of specialty and provider-administered drugs covered under the medical benefit; indicates which drugs require Prior Authorization (PA), are Limited Distribution Drugs (LDD), and/or have Quantity Limits (QL). Applies to providers and billing staff submitting claims for medical benefit drugs.

Policy Summary

PayerFlorida Blue

PolicyProvider-Administered Specialty Drugs (medical benefit list)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateCurrent 10/1/21

Next Review DateN/A

Key ActionSubmit Prior Authorization for any drug on the list marked 'PA' prior to administration and verify LDD dispensing site when a drug is marked 'LDD'.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~300drugs listed (approximate)

LDDDrugs designated Limited Distribution Drug

PADrugs requiring Prior Authorization

QLDrugs with Quantity Limits noted

Policy at a Glance

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

This document is a provider-facing maintained list enumerating specialty drugs covered under Florida Blue's medical benefit and flags whether each requires Prior Authorization (PA), is a Limited Distribution Drug (LDD), or has a Quantity Limit (QL). It is not exhaustive; providers must refer to the member contract, the Prior Authorization Program Information and Forms, and the PADP resources for final determination of coverage and program enrollment. The list is maintained with an effective date of Current 10/1/21 and is intended to help clinical and billing staff identify medical benefit drugs and any special handling noted by the plan.

ScopeList of specialty and provider-administered drugs covered under the medical benefit; indicates which drugs require Prior Authorization (PA), are Limited Distribution Drugs (LDD), and/or have Quantity Limits (QL). Applies to providers and billing staff submitting claims for medical benefit drugs.

SubjectProvider-Administered Specialty Drugs (medical benefit list)

EffectiveCurrent 10/1/21

StatusCURRENT

Coverage and Authorization Indicators

Coverage list indicates status flags next to each drug name; coverage is subject to member contract, PA program enrollment, and other plan limitations.

ALL of the following

Drugs listed are covered under the medical benefit unless otherwise restricted by member contract or plan.
Prior Authorization (PA) is required for drugs marked 'PA'.
PA requirements may vary by plan and member contract; see Prior Authorization Program Information and Forms.
Limited Distribution Drug (LDD) indicates the drug is only available from specific dispensing pharmacies.
Appropriate dispensing pharmacy can be found at the Limited Distribution Drugs resource.
Quantity Limit (QL) indicates limits apply to dosing/quantity where noted.
Presence on the list is not exhaustive — not all covered medical drugs or PA-required drugs are included here.

ALL of the following

Providers should consult member contracts and the PA program for plan-specific applicability and enrollment requirements.

Drug List and Flags (Medical Benefit)

Drug list entries with flagsNDC|drug_names

Abecma	PA
Adakveo	PA
Actemra IV	PA
Adagen	LDD
Aduhelm	LDD, PA
Aldurazyme	LDD, PA
Alferon
Alimta	PA
Aliqopa	PA
Amondys 45	LDD, PA

1–10 of 270

1/27

Operational note: drugs on the table include flag indicators — PA for Prior Authorization, LDD for Limited Distribution Drug, and QL for Quantity Limit — which are shown next to each drug name. Submission of a PA is required for drugs marked PA prior to administration per the plan's Prior Authorization Program Information and Forms; drugs marked LDD must be obtained from the designated dispensing pharmacy listed in the Limited Distribution Drugs resource and that dispensing source should be documented. Coverage is subject to the member contract and whether the drug is included in the plan's PA program; even if a drug appears on this list, coverage may be denied or handled differently depending on plan-specific rules and PADP enrollment.

What Providers Must Do

Prior Authorization

Prior Authorization required for marked drugs

Submit PA for any drug on the list marked 'PA' prior to administration per the plan's Prior Authorization Program Information and Forms.

All drug names flagged with 'PA' in the list

Documentation Required

Limited Distribution Drug dispensing site

For drugs marked 'LDD', obtain the appropriate dispensing pharmacy information from the Limited Distribution Drugs resource and document dispensing source.

All drug names flagged with 'LDD' in the list

Note

Buy-and-bill / PADP considerations

Providers enrolled in the Provider Administered Drug Program (PADP) who wish to buy-and-bill should consult the PADP section of the online provider manual for the current PADP drug list and operational requirements.

Denial Risk

Coverage may be denied if member contract exclusions apply

Even if a drug appears on the list, coverage may be denied or require different handling depending on the member's contract, plan-specific PA requirements, or if the drug is not included in the plan's PA program.

Key Definitions

Definitions

LDDLimited Distribution Drug — drug is only available from a specific dispensing pharmacy; check the Limited Distribution Drugs resource for dispensing location.

PAPrior Authorization — plan requires approval prior to administration for coverage.

QLQuantity Limit — numeric limit applied to quantity/dosing as noted by the plan.

PADPProvider Administered Drug Program — program for providers who buy-and-bill drugs; providers should consult online manual for enrollment and current PADP drug list.

Clinical / Administrative Background

Background: This list identifies specialty and provider-administered drugs recognized under the medical benefit and annotates drugs that require special handling or review. Limited Distribution Drugs (LDD) are drugs available only from specific dispensing pharmacies; see the Limited Distribution Drugs resource for dispensing locations. Prior Authorization (PA) indicates the plan requires approval prior to administration for coverage. Quantity Limit (QL) denotes numeric dosing or quantity restrictions where noted. Providers enrolled in the Provider Administered Drug Program (PADP) who intend to buy-and-bill should consult the PADP section of the online provider manual for the current PADP drug list and operational requirements.